Clinical Nurse Auditor - Rev Cycle
The University of Kansas Health System · United States
- Hybrid
- Full-time
- $80,000 / year
- United States
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Job highlights
- Auditing clinical services for revenue cycle optimization.
- Requires RN license and 2+ years of experience.
- Focuses on authorization, denial, and medical necessity.
- Remote position with The University of Kansas Health System.
- Collaborates across multiple departments for issue resolution.
About the role
Clinical Nurse Auditor - Rev Cycle
Position Summary / Career Interest
This role involves working with pre-certification, authorization, and denials teams to secure upfront authorization for services rendered. It requires clinical expertise in chart review, peer-to-peer requirements, and appeal processes. The position will also assist with denial management and resolution. Collaboration with HIM, PFS, Case Management, and various clinical departments is essential for resolving account issues related to service authorization and account resolution. For the Clinical Trials business line, duties include reviewing protocols to ensure billed services as standard of care are evidence-based and meet industry guidelines. Additionally, this role helps identify all services rendered as part of a clinical trial.
Responsibilities And Essential Job Functions
- Responsible for decreasing denied and inappropriately paid claims attributable to clinical and/or administrative reasons.
- Performs utilization review for correct patient setting (IP, OP, Observation) and correct patient status: Medical Necessity, Charge Audit reviews, Missing charges, Undocumented charges, completes documentation to support services per peer standards.
- Reviews high dollar & high-risk areas like transplants, Cancer Center and Cardiology.
- Uses clinical expertise to perform ongoing reviews of medical record documentation and clinical pertinence in accordance with peer standards and Medicare Regulations.
- Assists in tabulations of results and reports to management.
- Assists with a variety of clinical reviews as requested by members of the healthcare team and provides feedback.
- Supports process improvement activities to assure medical record compliance with regulatory and accreditation bodies.
- Collaborates with HIM coding staff and Patient Financial Services to investigate and resolve a variety of account problems related to clinical information.
- Monitors process effectiveness to identify trends and improvement opportunities.
- Assists with the development, implementation, and testing process improvement plans.
- Assists with quality improvement initiatives across the continuum of care as indicated: Authorization, Eligibility, Medical Necessity, Utilization Review, Documentation, Patient Status.
- Evaluates and resolves issues related to the revenue cycle including medical documentation, utilization review and medical necessity.
- Assists with documentation support and issue resolution in areas of charge capture, charge master, coding, claim submission and information system.
- Works with various departments and physician offices as necessary to resolve revenue cycle process conflicts.
- Provides training to improve revenue cycle processes.
- Recommends policies and procedures improvements to increase efficiencies in coordination with other areas of the department and with other departments.
- Provides necessary education and feedback to medical and ancillary staff to improve the overall quality of medical record documentation appropriate patient status orders, and clinical pertinence.
- Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.
Required Education And Experience
- Bachelor Degree Nursing
- 2 or more years experience in utilization review, clinical review, or authorizations
Preferred Education And Experience
- EPIC experience
Required Licensure And Certification
- Licensed Registered Nurse (LRN) - Multi-State - State Board of Nursing
- Current State RN license
Key skills/competency
- Clinical Nurse Auditor
- Revenue Cycle Management
- Utilization Review
- Medical Necessity
- Denial Management
- Authorization
- Clinical Documentation
- Registered Nurse
- Healthcare Auditing
- EPIC
Skills & topics
- Clinical Nurse Auditor
- Revenue Cycle
- Utilization Review
- Medical Necessity
- Denial Management
- Authorization
- Clinical Documentation
- Registered Nurse
- Healthcare Auditing
- Remote Work
- Bachelor of Science in Nursing
- EPIC
- Kansas
- Health System
- Full Time
How to get hired
- Customize your resume: Highlight your RN license, utilization review, and revenue cycle experience. Tailor keywords to match the job description, emphasizing authorization and denial management skills.
- Address specific requirements: Ensure your application clearly states your Bachelor's degree in Nursing and your 2+ years of relevant experience. Mention any EPIC system experience.
- Demonstrate clinical expertise: In your application and cover letter, provide examples of how you've used clinical knowledge to resolve account issues or improve revenue cycle processes.
- Showcase collaboration skills: Highlight your experience working with HIM, PFS, Case Management, and clinical departments to achieve shared goals.
- Prepare for interviews: Be ready to discuss your understanding of medical necessity, utilization review, and denial management in healthcare settings.
Technical preparation
Master medical necessity guidelines and Medicare regulations.,Understand chart review and documentation standards.,Familiarize yourself with revenue cycle workflows.,Practice using EHR systems like EPIC for auditing.
Behavioral questions
Describe a complex denial you resolved.,How do you prioritize competing audit tasks?,How do you collaborate with clinical teams?,How do you stay updated on healthcare regulations?
Frequently asked questions
- What are the primary responsibilities of a Clinical Nurse Auditor at The University of Kansas Health System?
- The Clinical Nurse Auditor is responsible for reviewing patient accounts to ensure proper authorization, medical necessity, and accurate billing. This includes working with denial management, performing utilization reviews, and collaborating with various departments to resolve revenue cycle issues.
- What qualifications are essential for the Clinical Nurse Auditor role?
- Essential qualifications include a Bachelor's Degree in Nursing, a Registered Nurse (RN) license, and at least two years of experience in utilization review, clinical review, or authorizations. Experience with EPIC is preferred.
- Is this Clinical Nurse Auditor position remote?
- Yes, this Clinical Nurse Auditor position is a remote role, allowing you to work from home.
- How does The University of Kansas Health System handle reasonable accommodations for applicants with disabilities?
- The University of Kansas Health System provides reasonable accommodations for qualified individuals with disabilities. If you need to request an accommodation during the recruitment process, you can request an Accommodation Request form by emailing asktalentacquisition@kumc.edu.
- What is the role of a Clinical Nurse Auditor in managing denials?
- Clinical Nurse Auditors play a crucial role in managing denials by identifying the root causes of denied claims, often related to clinical or administrative reasons, and working towards their resolution to improve the revenue cycle.
- Does The University of Kansas Health System require agreement to a dispute resolution program for employment?
- Yes, employment with The University of Kansas Health System is contingent upon agreeing to and signing their health-system-dispute-resolution-program.pdf.
- What kind of collaboration is expected for a Clinical Nurse Auditor?
- The Clinical Nurse Auditor is expected to collaborate closely with HIM, PFS, Case Management, and multiple clinical departments to resolve account problems related to authorizations and overall account resolution.